The Impact of Household Delivery of Family Planning Services on Women's Status in Bangladesh

Article excerpt

CONTEXT: Qualitative studies assessing the impact of the household delivery of family planning services on women's social status have yielded contradictory findings. Given the resumption of these services in Bangladesh in 2003, it is important to reevaluate the social impact of the doorstep program using quantitative techniques.

METHODS: Longitudinal and cross-sectional data from 3,783 women using doorstep services in two rural districts of Bangladesh are used in ordinary least-squares and logistic regression analyses to assess the effect of doorstep services on changes in women's status between 1988 and 1993.

RESULTS: In analyses controlling for background characteristics, women's status in 1988, previous service use and visit selection bias, household outreach is associated with increases in women's status between 1988 and 1993. However, this effect is largely attributable to the impact of doorstep services on women's ability to regulate their fertility rather than to the home visits themselves.

CONCLUSION: The decision of the Bangladesh Ministry of Health and Family Welfare to resume household family planning services should not be detrimental to women's status, and may be associated with gender benefits to female clients served by the program.

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From 1978 to 1997, the Bangladesh government hired and trained married women to provide family planning counseling and services to couples in rural households. At the peak of the program, a total of 28,000 of these "family welfare assistants" were working in hamlets throughout the country. * (1) By the early 1990s, evidence showed that doorstep service delivery had helped to increase family planning awareness, as well as the rate of method uptake and the continuity of method use, among rural couples. (2) Furthermore, by increasing access to reversible methods, the program helped to reduce the proportion of contraceptive users who adopted female sterilization (3)--a method that the government family planning program had heavily promoted. In areas where family welfare assistants had been trained to administer the injectable, the reduction in the reliance on sterilization was particularly pronounced and was also accompanied by a reduction in reliance on the pill. (4) Even so, overall pill use increased steadily following the initiation of doorstep delivery, with family welfare assistants providing nearly 85% of all pills dispensed in rural Bangladesh between 1978 and 1997. (5)

Despite these successes, various studies identified shortcomings in the program. First, doorstep services did not include child or reproductive health care, in large part because a legacy of organizational problems had separated health care and family planning in the government ministry responsible for the program. (6) Second, health and social service training, and supervisory and management problems affected the quality of services in the program. Client surveys suggest that services unduly focused on particular contraceptive methods and often omitted health service needs. (7) And recent qualitative research suggests that operational problems have persisted, even after health sector reforms. (8) Third, some family welfare assistants focused on better-educated women; targeting uneducated or poor women would have been more effective. (9) Finally, the policy of reaching couples was implemented as outreach that focused on female clients rather than on couples. The exclusion of men constrained the range of services offered and reduced the efficiency of outreach efforts. (10)

Whether doorstep service delivery affected women's autonomy and status is also unclear. Finding out the answer is important because Bangladesh is a patriarchal society, and Bangladeshi women have a lower status than do women in other Asian countries. (11) The low status of women in rural Bangladesh is detrimental to maternal and child health (12)--a finding that is consistent with research conducted elsewhere in South Asia, showing that women are more likely than men to contract infectious diseases. …